Clinical Evidence Concise
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Acute Low Back Pain
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Am Fam Physician. 2006 Sep 1;74(5):803-805.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The evidence is available at http://www.clinicalevidence.com/ceweb/conditions/msd/1102/1102.jsp.
What are the effects of oral drug treatments?
Nonsteroidal Anti-inflammatory Drugs. One systematic review and one subsequent randomized controlled trial (RCT) showed that nonsteroidal anti-inflammatory drugs (NSAIDs) increased overall improvement after one week compared with placebo. One systematic review and additional RCTs showed no significant difference in pain relief among NSAIDs or between NSAIDs and other drug treatments (i.e., paracetamol [acetaminophen], opioids, muscle relaxants, NSAIDs plus muscle relaxants). One systematic review provided insufficient evidence about the effects of NSAIDs compared with nondrug treatments.
TRADE-OFF BETWEEN BENEFITS AND HARMS
Muscle Relaxants. One systematic review showed that muscle relaxants decreased pain and improved overall clinical assessment compared with placebo, but the review showed no significant difference among different muscle relaxants. The review showed that benzodiazepine and nonbenzodiazepine muscle relaxants increased adverse effects (particularly drowsiness, dizziness, and nausea) compared with placebo.
Analgesics (Paracetamol [Acetaminophen], Opioids). We found no placebo-controlled RCTs on the effects of analgesics. Three small RCTs identified by a systematic review showed no significant difference in symptoms or time off from work among an opioid analgesic, paracetamol (acetaminophen), and an NSAID. Two small low-quality RCTs identified by another systematic review provided limited evidence that paracetamol (acetaminophen) and unspecified analgesics were less effective in achieving pain relief than electroacupuncture and ultrasound treatment, respectively.
What are the effects of local injections?
Epidural Steroid Injections. One systematic review provided no RCTs on the effects of epidural steroid injections in persons with acute low back pain.
What are the effects of nondrug treatments?
Advice to Stay Active. One systematic review and two subsequent RCTs showed that advice to stay active reduced sick leave and chronic disability compared with no advice or traditional medical treatment (e.g., analgesics as required, advice to rest, “let pain be your guide”). One systematic review showed that advice to stay active reduced pain and improved functional outcomes after three to four weeks and after 12 weeks compared with advice to rest in bed.
LIKELY TO BE BENEFICIAL
Multidisciplinary Treatment Programs (for Subacute Low Back Pain). One systematic review including persons with subacute low back pain provided limited evidence that multidisciplinary treatment, including a workplace visit, reduced sick leave compared with usual care.
Spinal Manipulation (in the Short Term). One systematic review and one subsequent RCT showed that spinal manipulation slightly reduced pain within six weeks compared with sham treatment, but they showed no significant difference in functional outcomes. The review showed no significant difference in pain or functional outcomes between spinal manipulative therapy and primary care, physical therapy, exercises, or back school.
UNLIKELY TO BE BENEFICIAL
Multidisciplinary Treatment Programs (for Acute Low Back Pain). We found no RCTs on the effects of multidisciplinary treatment programs in persons with acute low back pain.
Acupuncture. One systematic review provided insufficient evidence on the effects of acupuncture in persons with acute low back pain.
Back Schools. One systematic review provided insufficient evidence on the effects of back schools in persons with acute low back pain.
Behavior Therapy. One RCT identified by a systematic review provided limited evidence that cognitive behavior therapy reduced acute low back pain and disability after nine to 12 months compared with traditional care.
Electromyographic Biofeedback. We found no RCTs on the effects of electromyographic biofeedback.
Lumbar Supports. We found no RCTs on the effects of lumbar supports.
Massage. One RCT identified by a systematic review provided insufficient evidence on the effects of massage compared with spinal manipulation or electrical stimulation.
Temperature Treatments (Short Wave Diathermy, Ultrasonography, Application of Ice or Heat). Two systematic reviews identified no RCTs on the effects of temperature treatments.
Traction. Three systematic reviews identified no RCTs on the effects of traction in persons with acute low back pain.
Transcutaneous Electrical Nerve Stimulation. We found no RCTs on the effects of transcutaneous electrical nerve stimulation.
LIKELY TO BE INEFFECTIVE OR HARMFUL
Bed Rest. One systematic review showed increased pain and poorer functional outcomes after three to four weeks and after 12 weeks of advice to rest in bed compared with advice to stay active. RCTs identified by the review provided limited evidence that there is no significant difference in outcomes between advice to rest in bed and exercise or between three and seven days of bed rest. One of these RCTs provided limited evidence that there is no significant difference in pain among advice to rest in bed, exercise plus education, and no advice; whereas another of these RCTs showed limited evidence that there is no significant difference in improvement between bed rest and manipulation, drug therapy, physiotherapy, back school, or placebo. One systematic review showed that adverse effects of bed rest included joint stiffness, muscle wasting, decreased bone mineral density, pressure sores, and venous thromboembolism.
Back Exercises. One systematic review evaluating acute low back pain (less than six weeks in duration) showed no significant difference in pain or function between exercise and no treatment or between exercise and other conservative treatments. It provided limited evidence on subacute low back pain (six to 12 weeks in duration) that a graded activity exercise program may reduce time off from work associated with subacute low back pain compared with usual care; otherwise, it provided insufficient evidence on subacute low back pain.
Low back pain is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds with or without leg pain (sciatica),1 and is defined as acute when it persists for less than 12 weeks.2 Nonspecific low back pain is low back pain not attributed to a recognizable pathology (e.g., infection, tumor, osteoporosis, rheumatoid arthritis, fracture, inflammation).1 This chapter excludes acute low back pain with symptoms or signs at presentation that suggest a specific underlying condition. Persons with sciatica (lumbosacral radicular syndrome) and herniated disks also are excluded. Unless otherwise stated, persons included in this chapter have acute back pain. Some RCTs included in this chapter further subdivided acute low back pain of less than 12 weeks’ duration into acute (less than six weeks’ duration) or subacute (six to 12 weeks’ duration).
More than 70 percent of persons in developed countries will experience low back pain at some time in their lives.3 Each year, 15 to 45 percent of adults have low back pain, and one out of 20 (5 percent) present to a health care professional with a new episode. Low back pain is most common from 35 to 55 years of age.3 About 30 percent of European workers reported that their occupation caused them to have low back pain. Prevalence rates from different countries range from 13 to 44 percent. About 70 percent of persons who take sick leave because of low back pain return to work within one week, and 90 percent return within two months. However, as the period of sick leave increases, the likelihood that the person will return to work decreases. Less than one half of persons with low back pain who have been off of work for six months will return to work.3,4
Symptoms, pathology, and radiologic appearances are poorly correlated. Pain is nonspecific in about 85 percent of persons. About 4 percent of patients presenting in primary care with low back pain have compression fractures, and about 1 percent have a tumor.5 The prevalence of a prolapsed intervertebral disk is about 1 to 3 percent.3 Ankylosing spondylitis and spinal infections are less common.5 Risk factors for back pain include heavy physical work; frequent bending, twisting, and lifting; and prolonged static postures. Psychosocial risk factors include anxiety, depression, and mental stress at work.3,6
Acute low back pain usually is self-limiting (90 percent of persons recover within six weeks), although 2 to 7 percent develop chronic pain. Acute low back pain has a high recurrence rate: 50 to 80 percent of persons experience less severe recurrent symptoms within a year.7
search date: November 2004
Adapted with permission from Koes B, van Tulder M. Low back pain (acute). Clin Evid 2006;15:416–8.
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2. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642. Rockville, Md.: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
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4. Waddell G. The Back Pain Revolution. Edinburgh, U.K.: Churchill Livingstone, 1998.
5. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?. JAMA. 1992;268:760–5.
6. Bongers PM, de Winter CR, Kompier MA, et al. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health. 1993;19:297–312.
7. Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988;318:291–300.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinical-evidence.com. If you are interested in contributing to Clinical Evidence, please send an e-mail to CEcommissioning@bmj.com. This series is part of the AFP’s CME. See “Clinical Quiz” on page 711.
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